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Extension Request Application - Medicaid.gov

Extension Request Application - Medicaid.gov 2026

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The document is a Clinical Eligibility Form from the State of Montana's Department of Public Health and Human Services, specifically for the Addictive & Mental Disorders Division. It is used to assess applicants seeking mental health services under the Mental Health Services Plan (MHSP) and Waiver for Additional Populations (WASP). The form collects detailed applicant information, clinical diagnoses, treatment history, and current risk factors to determine eligibility for services.

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Click ‘Get Form’ to open the Extension Request Application in our editor.
Begin by filling out the 'Applicant Information' section. Enter the date of intake appointment, referral source, applicant ID/SSN, date of birth, gender, and full name. Ensure that your mailing address is complete with city, county, and zip code.
In the 'Provider Agency Information' section, input the agency's name, clinician's email address, and contact details including address and telephone number.
Proceed to the 'Clinical Information' section. List current DSM5/ICD-10 diagnoses along with any relevant medical conditions. Provide details about medications including dosage and prescriber information.
Answer questions regarding treatment history and current risk factors. Be thorough in describing any challenges faced due to mental illness.
Finally, ensure that both provider and supervisor signatures are included before submitting the form via mail or fax as indicated at the bottom of the document.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the Medicaid extension?

Medicaid expansion provides coverage across age groups for those 19 to 64 (Figure 3). Many expansion adults are working; however, they work for employers and in industries that are less likely to offer health insurance, leaving them without affordable health coverage options.

Who pays for expanded Medicaid?

The federal government or each state? The cost of Medicaid expansion is paid by both the state and federal government, but the federal government pays 90% of the cost.

Is Medicaid expansion good or bad?

Access to care and related measures: Most research demonstrates that Medicaid expansion has improved access to care, utilization of services, the affordability of care, and financial security among the low-income population.

How do I get my Medicaid renewed?

California Enrollment. ☎ Call the Medi-Cal Helpline: 800-541-5555, or 916-636-1980. To contact your county for a renewal, find the phone number here.

What is a Medicaid extension?

The Affordable Care Act (ACA) permits states to expand Medicaid coverage to adults with incomes up to 138 percent of the poverty level (about $20,780 annually for an individual or $35,630 for a family of three).

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How do I contact Medicaid in Arkansas?

★ Arkansas Medicaid Arkansas State Contacts. Eligibility. Enrollment. ☎ Coverage, Bills, Denial letters, Other services: 800-482-5431. ☎ Lost/non-receipt of Medicaid cards, Eligibility: Toll-Free: 800-482-8988, Local: 501-682-8233.

How to apply for expanded Medicaid in NC?

People can apply for Medicaid online at epass.nc.gov. They can also submit a paper application or apply in person at their local Department of Social Services (DSS). Applications may take up to 45 days to process. Incomplete applications may take longer.

Who is eligible for Medicaid expansion in North Dakota?

Medicaid Expansion is available to individuals between 19-64 with household incomes up to 138% of the federal poverty level (FPL). Individuals eligible for Medicare or Supplemental Security Income (SSI) are not eligible for coverage under Medicaid Expansion.

Extension Request Application - Medicaid.gov 2026

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What is the Medicaid extension?

Who pays for expanded Medicaid?

Is Medicaid expansion good or bad?

How do I get my Medicaid renewed?

What is a Medicaid extension?

Security and compliance

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How do I contact Medicaid in Arkansas?

How to apply for expanded Medicaid in NC?

Who is eligible for Medicaid expansion in North Dakota?

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